diverticular disease - medical residency...
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Diverticular DiseaseDiverticular Disease
Bindhu Oommen, MD
Brian J. Daley, MDBrian J. Daley, MD
CASECASE
• 81 y/o man with several hour history of painless y/ y pBRBPR after heavy lifting
• ROS: no NSAID/ASA use; no h/o PUD• PMH: glaucoma, HTN, inguinal hernia• PSH: eye surgery, IHR• Meds: Tenormin, Minoxidil, Catapres, Benicar• NKDA
f f• FHx: negative for cancer; positive for CVA• SHx: Denied smoking/alcohol/illicit drugs
CASECASE
• VS: T 98.1, P 118, BP 203/95, RR 18, 97% RA, , / , ,• Gen: mild distress• HEENT: wnl• CV: irregular• Resp: CTAB• GI: soft/NT/ND• Rectal: blood in rectal vault; no hemorrhoids• GU: wnl• Neuro: wnl
CASECASE
• Labs:
142 109 25 96
4.2 23 1.02 9.1
12.5
9.4 225
37.2LFTs 0.8/ 68/ 15/ 10
• GI consult: Hct dropped to 30.4 over 16 hours. HDS. Planned colonoscopy and EGD
EGD: 5 cm hiatal hernia; benign gastric fundic polyps; otherwise– EGD: 5 cm hiatal hernia; benign gastric fundic polyps; otherwise esophagus to duodenal bulb unremarkable
– C‐scope: pandiverticulosis with old blood throughout colon and distal TI; proximal ileum without blood; p
CASECASE
• Tagged RBC scan: positive for active bleedingTagged RBC scan: positive for active bleeding in cecum/ascending colon
• Multiple transfusions with continued decline• Multiple transfusions, with continued decline in Hct
S l i i d l• Surgery: laparoscopic assisted total abdominal colectomy
• Pathology pending
TopicTopic
• LGIBLGIB
• Diverticular disease
LGIBLGIB
• Definiton: bleeding distal to ligament of TreitzDefiniton: bleeding distal to ligament of Treitz
• Hematochezia• Most common cause UGIB• Most common cause: UGIB
• Initial evaluation:– NGT aspiration: bilious vs. bloodyp y
– EGD
• Melena• Indicates UGIB
LGIBLGIB
• Once you have ruled out UGIBOnce you have ruled out UGIB….….most common cause of LGIB is……..diverticular
disease!disease!
• Minor: stable vital signs/workup outpatient
M j b l VS lt d LOC 2 U• Major: abnormal VS, altered LOC, > 2 U PRBCs
• Massive: >10 Units
LGIBLGIB
Source of Bleeding Percent
Colonic diverticula 32.7
Hemorrhoids 27.1
Cancer 8.1
Inflammatory bowel disease 6.7
Angiodysplasia 5 3Angiodysplasia 5.3
Polyps 4.9
Ischemic colitis 4.5sc e c co t s 5
Rectal ulcer 2.4
Post polypectomy 0.6
Miscellaneous 7.7Source: Cameron. Current Surgical Therapy. 9th ed.
LGIB—Evaluation/AssessmentLGIB Evaluation/Assessment
• Emergent exploratory laparotomyEmergent exploratory laparotomy
• Urgent Nonoperative EvalutionC l– Colonoscopy
– Tagged RBC scan (0.1 ml/min)
( / )– Mesenteric angiography (0.5 ml/min)
• Nonemergent Operation– Hemicolectomy
– TAC (total abdominal colectomy)
LGIB—Evaluation/AssessmentLGIB Evaluation/Assessment
• After bleeding ceasesAfter bleeding ceases– Colonoscopy: if normal, presume SB origin
Push enteroscopy– Push enteroscopy
– Capsule endoscopy
DIVERTICULAR DISEASEDIVERTICULAR DISEASE
• DiverticulosisDiverticulosis– What are they and where on colon do they occur?
• A: outpouchings usually occurring at the site whereA: outpouchings, usually occurring at the site where blood vessels penetrate the bowel wall
• DiverticulitisDiverticulitis– Inflammation/infection around colonic diverticulum
DiverticulosisDiverticulosis
• 50% of massive LGIB50% of massive LGIB
• Stops spontaneously in more than 70% cases
f f bl di k• If source of bleeding not known– Blind subtotal/total colectomy with ileorectal anastomosis
– Lesser segmental resections associated with 30% bl direbleeding
DiverticulitisDiverticulitis
• Uncomplicated: absence of abscess, free p ,perforation, fistulization, stenosis– Presentation: pain, fever, leukocytosis, mass
l l h ld f– Diagnosis: clinical with mild forms– Management:
• Bowel rest• Antibiotics (which ones?)
– What percent resolve without recurrence? 70%Elective colonoscopy after 6 8 weeks– Elective colonoscopy after 6‐8 weeks
– Goal w/ surgical resection: remove diseased segment and resect remaining distal sigmoid colon down to rectum
Diverticulitis: Indications for SurgeryDiverticulitis: Indications for SurgeryStrictly Indicated by Available Literature
Available Literature Conflicting
Previous Indications No Longer Well Supported by g g pp yAvailable Data
Diffuse peritonitis Following successful percutaneous drainage of b
Uncomplicated first episode, even in patients aged <50
abscess
Free perforation
ObstructionObstruction
Stricture
Fistula
Immunocompromised patients
> 4 uncomplicated episodes
Source: Cameron. Current Surgical Therapy. 9th ed.
Complicated DiverticulitisComplicated Diverticulitis
• Associated with abscess formation freeAssociated with abscess formation, free perforation, fistula, stenosis
• Hinchey: Clinical staging for perforated• Hinchey: Clinical staging for perforated diverticulitis
Clinical Staging f f d lof Perforated Diverticulitis
Hughes/Cuthbertson/ C d St i (1963)Hinchey Staging (1978) Carden Staging (1963)
Stage I Pericolic or intramesenteric abscess
Local peritonitis
Stage II Walled‐off pelvic abscess Local pericolic or pelvic abscess
Stage III Generalized purulent peritonitis caused by ruptureof an abscess into general
Generalized peritonitis caused by ruptured pericolic or pelvic abscess
abdominal cavity
Stage IV Generalized fecal peritonitis caused by free perforation
General peritonitis caused by free perforation of the colony p p
Source: Cameron. Current Surgical Therapy. 9th ed.
Complicated DiverticulitisComplicated Diverticulitis
• Stage I and II (contained perforation)Stage I and II (contained perforation)– IV antibiotics & observation possibly for Stage I– PCD for those who fail to improve rapidlyp p y– Then elective colonoscopy at 6‐8 weeks
• Stage III and IV (free perforation)Stage III and IV (free perforation)– shock, generalized peritonitis, free air– Aggressive fluid resuscitationgg– Broad‐spectrum antibiotics– Urgent operative managementg p g
Principles of Surgical ResectionPrinciples of Surgical Resection
• Peform primary resection• Proximal resection margin should be normal colon without
palpable hypertrophy of muscularis layer• Distal resection margin must be in proximal rectum, where g p
tenia coli coalesce– Exceptions: Unstable patient; mucus fistula
• Not necessary to resect all diverticulae‐bearing proximal colon• Oncologic operation if cancer not excluded preoperatively by
endoscopy• Ureteral stents• If complete distal sigmoid resection not done, document and
tell the patient
Complications continuedComplications continued
• Abscess (already talked about)Abscess (already talked about)
• FistulaM t l i l– Most common: colovesical
• Stenosis/Obstruction
REFERENCESREFERENCES
• Cameron Current Surgical Therapy 9th edCameron. Current Surgical Therapy. 9 ed.
• Townsend. Atlas of General Surgical TechniquesTechniques.